Pediatric Central Venous Catheter Malfunction / Malposition / Misposition / Misplacement

  • Etiology: placed in patients who require long-term infusions, most commonly chemotherapy
  • Imaging: catheter tip should be pointing inferiorly in superior vena cava or at cavo-atrial junction
  • Complications: initial malposition of catheter tip, port leaking, catheter broken or leaking, catheter tip migrated either out of vessel or occluded against wall of vessel, fibrin sheath or thrombus at catheter tip, retained or embolized catheter fragment or fibrin sheath after catheter removal
  • Treatment: fibrin sheath and thrombus treated with tissue plasminogen activator (TPA) infusion
  • Clinical: presents with failure to infuse or draw back through catheter

Radiology Cases of Central Venous Catheter Malfunction / Malposition / Misposition / Misplacement

Radiology Cases of Central Venous Catheter Normal Appearance

Line study showing dual port central venous catheter
Image from a line study while injecting the white port of the catheter (left lower) shows the lumen of the white port is one-third the diameter seen while injecting the red port of the catheter (right lower). No fibrin sheath or clot was seen.

Radiology Cases of Central Venous Catheter Malposition

CXR showing central venous catheter tip malpositioned in the right internal thoracic vein
CXR AP obtained immediately after catheter placement (above) shows the catheter tip malpositioned in the right internal thoracic vein. CXR AP obtained after repositioning (below) shows catheter tip appropriately positioned in the superior vena cava.

Radiology Cases of Central Venous Catheter Port Not Correctly Accessed

Line study of a central venous catheter port that was not correctly accessed
Image from a catheter injection (below) shows extravasation of contrast into the soft tissues of the chest wall adjacent to the tip of the needle. Closer review of the CXR scout (above) shows the tip of the needle being used to access the port is not within the port.

Radiology Cases of Central Venous Catheter Port Leaking

Line study of a leaking central venous catheter port
AP and lateral views from a line study shows contrast leaking out of and all around the port into the subcutaneous tissues with no contrast entering the catheter.

Radiology Cases of Central Venous Catheter Leaking

Line study of a leaking central venous catheter
Image from a line study while injecting contrast shows leakage of contrast out of the proximal portion of the catheter.

Radiology Cases of Central Venous Catheter Migrated and Occluded Against Wall of Vessel

Line study of central venous catheter with an occluded tip
CXR from 2 weeks earlier (above) shows the tip of the catheter in appropriate position at the junction of the superior vena cava and the right atrium. Scout image from a line study (below) shows the tip of the catheter has migrated backwards in the interval and its tip now rests against the wall of the superior vena cava.
Line study of occluded central venous catheter due to migration
Scout image from a line study shows migration of the tip of the catheter so that it now lies flush against the lateral wall of the superior vena cava.
Line study of an occluded central venous catheter due to migration
CXR from 3 months before (above) shows the tip of the catheter in appropriate position in the superior vena cava. Scout image from the line study (below) shows interval migration of the tip of the catheter so that its tip now lies nearly flush against the lateral wall of the superior vena cava.

Radiology Cases of Central Venous Catheter Migrated Out of Vessel

Line study of a central venous catheter tip that has migrated out of the vessel
CXR from 1 month before (above) shows the tip of the catheter in a left-sided superior vena cava. Scout image from a line study (below left) shows the tip of the catheter has apparently migrated out of the left-sided superior vena cava. Injection of the catheter (below right) shows contrast extravasating into the mediastinum.

Radiology Cases of Central Venous Catheter Fibrin Sheath

Line study of a fibrin sheath on a central venous catheter
Scout from a line study (above) shows the tip of the catheter to be abnormally positioned in the right subclavian vein rather than in the superior vena cava. Injection of the catheter (below) shows a dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter.
Line study of a fibrin sheath on a central venous catheter
Image from a line study (above) shows a subtle dilation in the diameter of the distal catheter, which is better seen on the magnified view (below), suggesting the contrast is inside a sheath encasing the distal catheter.
Line study of a fibrin sheath on a central venous catheter
CXR obtained 6 months before (above left) compared to the scout image obtained before the line study (above right) shows the tip of the catheter has migrated proximally the height of one vertebral body between the two exams. Image from the line study (below) shows contrast outlining a sheath where the catheter tip used to be.
Line study of a fibrin sheath on a central venous catheter
Image from a line study (above) with the catheter filled with contrast shows a mild dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter. When contrast is injected through the catheter (below), a sheath is seen to flip off the tip of the catheter to the left.

Radiology Cases of Central Venous Catheter Thrombus

Line study of a thrombus on a central venous catheter
Scout image from a line study (above) shows the tip of the catheter in the superior vena cava. Injection of contrast (below) shows staining of a large irregularly shaped object resembling thrombus at the tip of the catheter.
Line study of a thrombus on a central venous catheter
Scout image from a line study (above) shows migration of the tip of the catheter 90 degrees so that it now lies flush against the anterior wall of the superior vena cava. AP and lateral views from the line study after contrast injection shows staining of a long thin object resembling thrombus hanging off the tip of the catheter.

Radiology Cases of Central Venous Catheter Embolized Fragment

CXR and CT of embolized central venous catheter fragment
CXR AP shows the tip of the new catheter to be in appropriate location in the superior vena cava. There is a catheter fragment in the right lower lobe along with a large right pleural effusion. Axial CT with contrast of the chest shows the embolized catheter fragment in the periphery of the right lower lobe and to have eroded into the right pleural space, with an associated pleural effusion and atelectasis.

Radiology Cases of Central Venous Catheter Embolized Fibrin Sheath After Catheter Removal

CT of an embolized fibrin sheath from a central venous catheter
CXR shows no evidence of pneumonia, but suggests the presence of a tubular structure in the inferior aspect of the left hilum that was not present on a prior CXR obtained before the catheter was replaced. Coronal image from a CT with contrast of the chest better demonstrates the high density tubular structure.